Neurological Medical Records Release Form
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1Chart # ________________
Austin Neurological Clinic
Medical Records Release Form
Patient Name : ______________________________________________ DOB: __________________
SS#: ____________________________________
Doctor: _____________________________
By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my
medical record, or a summary or narrative of my protected health information, to the person(s) or entity listed below.
Dictation only (no charge)
□
Complete record ($25.00 for first 20 pages, $.50 per page thereafter)
□
Records of care from the following dates:
_______________ to _________________
□
Records concerning the following condition: __________________________________
□
Other, please specify _____________________________________________________
□
Confer with person listed below orally about my medical information
□
Release my protected health information:
From
To
Name: _____________________________________
Name: _______________________________________
Street: _____________________________________
Street: _______________________________________
City: ____________ State: _____ Zip: __________
City: ____________ State: _____ Zip: __________
Including information (if applicable) pertaining to:
_______Mental Health _______Drugs/Alcohol
_______HIV / AIDS: I consent to the release of
any positive or negative test result for AIDS or HIV infection, antibodies to AIDS or infection with any
Patient Name:
other causative agent of AIDS with the rest of my medical records.
Initial: ____________________
Date: ______________________
Limitations on the information you may release subject to this Release Form are as follows:
The reasons or purposes for this release of information are as follows:
Continued patient care
□ Personal Use
□ Insurance Claim/Application
□
Disability Determination
□ Attorney/Legal
□ Other _____________________
□
I understand that I may revoke this authorization at any time. If I fail to specify an expiration date, this
authorization will expire in six months. I understand that you will provide this information within 15 business
days from receipt of request and that a fee for preparing and furnishing this information may be charged
according to rulings set forth by the Texas State Board of Medical Examiners.
___________________________________________
________________________
Signature of Patient or Legal Representative
Date
___________________________________________
________________________
Relationship to Patient
Witness
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